In Vivo Accessories for Minimally Invasive Surgery

ABSTRACT

Surgical accessories are presented in vivo and used by surgical tools in the surgical site to perform additional tasks without the need to remove the tools from the surgical site for tool change or instrument loading. The accessories can be introduced into the surgical site by a dedicated accessory introducer, or can be supported on the body of a surgical tool inserted into the surgical site and be manipulated using another surgical tool in the surgical site. The accessory introducer can be resiliently biased to bias the accessories toward a predetermined position in the surgical site.

CROSS-REFERENCES TO RELATED APPLICATIONS

This application is a division of U.S. patent application Ser. No.11/522,852, filed Sep. 18, 2006, which is a division of U.S. patentapplication Ser. No. 10/116,504 filed Apr. 3, 2002, now U.S. Pat. No.7,125,403, which is a continuation-in-part of and claims benefit fromU.S. patent application Ser. No. 09/478,953, filed Jan. 7, 2000, nowU.S. Pat. No. 6,770,081, which is a continuation-in-part of U.S. patentapplication Ser. No. 09/453,978, filed Dec. 2, 1999, now U.S. Pat. No.6,309,397, and claims benefit from U.S. Provisional Application No.60/111,711, filed Dec. 8, 1998, the complete disclosures of which areincorporated herein by reference.

This application is related to the following patents and patentapplications, the full disclosures of which are incorporated herein byreference: PCT International Application No. PCT/US98/19508, entitled“Robotic Apparatus”, filed on Sep. 18, 1998, U.S. application Ser. No.09/418,726, entitled “Surgical Robotic Tools, Data Architecture, andUse”, filed on Oct. 15, 1999; U.S. Application Ser. No. 60/111,711,entitled “Image Shifting for a Telerobotic System”, filed on Dec. 8,1998; U.S. application Ser. No. 09/378,173, entitled “Stereo ImagingSystem for Use in Telerobotic System”, filed on Aug. 20, 1999; U.S.application Ser. No. 09/398,507, entitled “Master Having RedundantDegrees of Freedom”, filed on Sep. 17, 1999, U.S. application Ser. No.09/399,457, entitled “Cooperative Minimally Invasive TelesurgerySystem”, filed on Sep. 17, 1999; U.S. Provisional application Ser. No.09/373,678, entitled “Camera Referenced Control in a Minimally InvasiveSurgical Apparatus”, filed on Aug. 13, 1999; U.S. Provisionalapplication Ser. No. 09/398,958, entitled “Surgical Tools for Use inMinimally Invasive Telesurgical Applications”, filed on Sep. 17, 1999;and U.S. Pat. No. 5,808,665, entitled “Endoscopic Surgical Instrumentand Method for Use”, issued on Sep. 15, 1998.

BACKGROUND OF THE INVENTION

Advances in minimally invasive surgical technology could dramaticallyincrease the number of surgeries performed in a minimally invasivemanner. Minimally invasive medical techniques are aimed at reducing theamount of extraneous tissue that is damaged during diagnostic orsurgical procedures, thereby reducing patient recovery time, discomfort,and deleterious side effects. The average length of a hospital stay fora standard surgery may also be shortened significantly using minimallyinvasive surgical techniques. Thus, an increased adoption of minimallyinvasive techniques could save millions of hospital days, and millionsof dollars annually in hospital residency costs alone. Patient recoverytimes, patient discomfort, surgical side effects, and time away fromwork may also be reduced with minimally invasive surgery.

The most common form of minimally invasive surgery may be endoscopy.Probably the most common form of endoscopy is laparoscopy, which isminimally invasive inspection and surgery inside the abdominal cavity.In standard laparoscopic surgery, a patient's abdomen is insufflatedwith gas, and cannula sleeves are passed through small (approximately ½inch) incisions to provide entry ports for laparoscopic surgicalinstruments. The laparoscopic surgical instruments generally include alaparoscope (for viewing the surgical field) and working tools. Theworking tools are similar to those used in conventional (open) surgery,except that the working end or end effector of each tool is separatedfrom its handle by an extension tube. As used herein, the term “endeffector” means the actual working part of the surgical instrument andcan include clamps, graspers, scissors, staplers, and needle holders,for example. To perform surgical procedures, the surgeon passes theseworking tools or instruments through the cannula sleeves to an internalsurgical site and manipulates them from outside the abdomen. The surgeonmonitors the procedure by means of a monitor that displays an image ofthe surgical site taken from the laparoscope. Similar endoscopictechniques are employed in, e.g., arthroscopy, retroperitoneoscopy,pelviscopy, nephroscopy, cystoscopy, cisternoscopy, sinoscopy,hysteroscopy, urethroscopy and the like.

There are many disadvantages relating to current minimally invasivesurgical (MIS) technology. For example, existing MIS instruments denythe surgeon the flexibility of tool placement found in open surgery.Most current laparoscopic tools have rigid shafts, so that it can bedifficult to approach the worksite through the small incision.Additionally, the length and construction of many endoscopic instrumentsreduces the surgeon's ability to feel forces exerted by tissues andorgans on the end effector of the associated tool. The lack of dexterityand sensitivity of endoscopic tools is a major impediment to theexpansion of minimally invasive surgery.

Minimally invasive telesurgical robotic systems are being developed toincrease a surgeon's dexterity when working within an internal surgicalsite, as well as to allow a surgeon to operate on a patient from aremote location. In a telesurgery system, the surgeon is often providedwith an image of the surgical site at a computer workstation. Whileviewing a three-dimensional image of the surgical site on a suitableviewer or display, the surgeon performs the surgical procedures on thepatient by manipulating master input or control devices of theworkstation. The master controls the motion of a servo mechanicallyoperated surgical instrument. During the surgical procedure, thetelesurgical system can provide mechanical actuation and control of avariety of surgical instruments or tools having end effectors such as,e.g., tissue graspers, needle drivers, or the like, that perform variousfunctions for the surgeon, e.g., holding or driving a needle, grasping ablood vessel, or dissecting tissue, or the like, in response tomanipulation of the master control devices.

A typical surgery employs a number of different surgical instruments.When a different tool is desired during the surgical procedure, thesurgical instrument is typically withdrawn from the surgical site sothat it can be removed from its associated arm and replaced with aninstrument bearing the desired end effector. The desired surgicalinstrument is then inserted into the surgical site.

A surgical instrument may also be withdrawn from a surgical site forreasons other than to replace the end effector. For example, the loadingof a clip in a clip applier used in affixing tissue typically occursoutside of the patient's body. Each time a new clip is desired, the clipapplier is removed from the surgical site to load the clip and thenreintroduced into the patient's body to apply the clip. Tool exchangeand instrument loading for a robotic system takes time. Providingadditional surgical instruments in the surgical site (and the typicallyassociated need to make additional incisions in the patient's body) maybe an undesirable alternative for any number of reasons, e.g., due tospace constraints, increase in system complexities, and/or cost.

SUMMARY OF THE INVENTION

The present invention is generally directed to robotic surgery methods,devices, and systems. The invention overcomes the problems anddisadvantages of the prior art by providing surgical clips and/or otherin vivo accessories at the surgical site. These in vivo accessories canbe manipulated by robotic surgical tools in the site for performingdifferent tasks. The accessories can be held by a dedicated accessoryholder or support that is introduced into the surgical site through aseparate opening. Alternatively, the accessories can be supported on thebody of one of the surgical tools, and can be manipulated using anothersurgical tool in the surgical site. The surgical tools in the surgicalsite can use the accessories for performing a wide range of additionaltasks without leaving the surgical site. In this way, the need toexchange tools and load instruments outside the surgical site isreduced, thereby minimizing “down time”.

In accordance with an aspect of the present invention, a method ofperforming minimally invasive robotic surgery in a body cavity of apatient includes introducing at least one surgical accessory and arobotic surgical tool into the cavity. The surgical accessory is coupledwith the robotic surgical tool inside the cavity after introducing thesurgical accessory and the robotic surgical tool into the cavity. Thesurgical accessory may be decoupled from the robotic surgical toolinside the cavity.

In some embodiments, the robotic surgical tool is used to grasp thesurgical accessory inside the cavity of the patient. In otherembodiments, the surgical accessory is mated with the robotic surgicaltool to form a mated connection. The surgical accessory may be coupledwith the robotic surgical tool by introducing a second robotic surgicaltool into the cavity and using it to facilitate coupling of the surgicalaccessory with the first surgical tool.

In certain preferred embodiments, the surgical accessory is introducedinto the cavity supported by a surgical accessory support and thesurgical accessory is removable from the surgical accessory supportwithin the cavity. In a specific embodiment, the surgical accessorysupport includes a container. In another embodiment, the surgicalaccessory support includes a block having a material which deflects toreleasably secure one or more surgical accessories therein. In yetanother embodiment, the surgical support is provided on the body ofanother robotic surgical tool introduced into the cavity.

In a specific embodiment, a cartridge is introduced into the cavity toprovide a plurality of surgical clips. The surgical tool is a clipapplier. The clips are sequentially loaded in the clip applier withinthe cavity and the loaded clips are affixed to a target tissue with theclip applier.

In some embodiments, a portion of a master control device locatedremotely from the patient is actuated by a user to control the roboticsurgical tool to grasp the surgical accessory. The robotic surgical toolmay be instructed to continue to grasp the surgical accessory withoutrequiring the user to continue to actuate the actuatable portion of themaster control device.

In accordance with another aspect of the invention, a method ofperforming minimally invasive robotic surgery in a body cavity of apatient includes introducing a robotic fastening tool and a surgicalaccessory support into the cavity. The surgical accessory supportsupports a plurality of fastening accessories. One of the fasteningaccessories is loaded in the robotic fastening tool inside the cavity.The loaded fastening accessory is affixed to a target tissue inside thecavity with the robotic fastening tool.

In a specific embodiment, the robotic fastening tool is a clip applierand the fastening accessories include a plurality of surgical clips. Theclips are supported on a clip cartridge or on the body of anotherrobotic surgical tool introduced into the cavity.

Another aspect of the present invention is directed to a roboticsurgical system for effecting a predetermined treatment of a targettissue at an internal surgical site within a patient body. The systemincludes a surgical accessory adapted for effecting the treatment, andan accessory introducer having a proximal end and a distal end with anopening therebetween. The distal end of the introducer is insertableinto the patient body so that the opening defines a first minimallyinvasive aperture. The surgical accessory is coupled with the distal endof the introducer and is passable through the opening to the internalsurgical site. A robotic arm supports a surgical tool having an endeffector suitable for insertion through a second minimally invasiveaperture to the internal surgical site. The end effector is coupleablewith the surgical accessory within the internal surgical site so thatthe robot arm can manipulate the surgical accessory to direct thetreatment to the target tissue.

In some embodiments, the accessory comprises a tool tip configured to bereleasably coupled to an end effector working member of the surgicaltool to form a tool tip for the end effector. In specific embodiment,the end effector comprises a pair of working members and the accessorycomprises a pair of fingers movably supported on a collar which isconfigured to be releasably coupled with the surgical tool in a coupledposition. The pair of fingers mate with the pair of working members tobe movable by the pair of working members in the coupled position.

Another aspect of the invention is directed to an apparatus forproviding a surgical accessory in vivo through a wall of a patient bodyinto an internal cavity of the patient body for effecting a desiredtreatment of a target tissue in the patient body. The apparatus includesa surgical accessory adapted for effecting the treatment and anaccessory introducer having a proximal end and a distal end with anopening therebetween. The distal end of the introducer is insertableinto the patient body so that the opening defines a first minimallyinvasive aperture. The surgical accessory is coupled with the distal endof the introducer and passable through the opening to the internalcavity. A resilient member is connected with the accessory introducer toresiliently bias the surgical accessory to a preset desired locationwithin the internal cavity.

In a specific embodiment, the accessory introducer includes a supportmember configured to be anchored to the wall of the patient body at theopening. A slidable member is coupled with the surgical accessory and isslidable relative to the support member. The resilient member includes aspring coupled between the support member and the slidable member.

In accordance with another aspect of the invention, a method ofperforming minimally invasive robotic surgery in an internal cavity of apatient body includes supporting a portion of a target tissue with afirst robotic surgical tool introduced into the internal cavity. Thefirst robotic surgical tool is electrically conductive. The methodfurther includes contacting another portion of the target tissue with anelectrically conductive cautery member introduced into the internalcavity. The first robotic surgical tool and the cautery member areenergized for coagulating the target tissue. In some embodiments, thefirst robotic surgical tool and the cautery member are energized byconnecting them to opposite leads of a radio frequency power source toform a bipolar system. In a specific embodiment, the cautery member isheld by a second robotic surgical tool and electrically insulatedtherefrom.

In accordance with yet another aspect of the invention, a roboticsurgical system for performing a procedure on a body comprises asurgical tool having an end effector including at least two end effectormembers, the members capable of grasping an object. A master controldevice has-an actuatable portion which is operatively connected to thesurgical tool such that actuation of the portion causes the at least twoend effector members to grasp the object. The system includes an inputdevice for accepting an input from a user to cause the end effectormembers to continue to grasp without further actuation of the actuatableportion of the master control device.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a perspective view of an operator station of a telesurgicalsystem in accordance with an embodiment of the invention;

FIG. 1B is a perspective view of a cart or surgical station of thetelesurgical system according to an embodiment of the invention, thecart of this particular embodiment carrying three robotically controlledarms, the movement of the arms being remotely controllable from theoperator station shown in FIG. 1A;

FIG. 2A is a side view of a robotic arm and surgical instrument assemblyaccording to an embodiment of the invention;

FIG. 2B is a perspective view of the robotic arm and surgical instrumentassembly of FIG. 2A;

FIG. 3 is a perspective view of a surgical instrument according to anembodiment of the invention;

FIG. 4 is a schematic kinematic diagram corresponding to the side viewof the robotic arm shown in FIG. 2A, and indicates the arm having beendisplaced from one position into another position;

FIG. 5 is a perspective view of a wrist member and end effector of thesurgical instrument shown in FIG. 3, the wrist member and end effectorbeing movably mounted on a working end of a shaft of the surgicalinstrument;

FIG. 6A is a perspective view of a hand held part or wrist gimbal of amaster control device of the telesurgical system;

FIG. 6B is a perspective view of an articulated arm portion of themaster control device of the telesurgical system on which the wristgimbal of FIG. 6A is mounted in use;

FIG. 6C is a perspective view of the master control device showing thewrist gimbal of FIG. 6A mounted on the articulated arm portion of FIG.6B;

FIGS. 6D and 6E depict a preferred embodiment of the master controldevice shown in FIGS. 6A-6C having a locking mechanism for locking theslave end effector into an actuated position;

FIG. 7 is a perspective view of a clip applier end effector inaccordance with the invention;

FIG. 8 is an exploded view of the clip applier end effector shown inFIG. 7;

FIG. 9 is a schematic view of a clip cartridge for supplying clips invivo to a clip applier;

FIG. 10 is a schematic view illustrating supply of clips in vivo byanother surgical tool in the surgical site;

FIG. 11 is a perspective view showing examples of different singleworking member accessories;

FIG. 11A is a schematic view illustrating a way of performingelectrocautery;

FIG. 11B is a schematic view illustrating another way of performingelectrocautery;

FIG. 12 is a side view of forceps;

FIG. 13 is a perspective view of a surgical accessory support blockaccording to an embodiment of the invention;

FIG. 14 is a perspective view of a surgical accessory containeraccording to another embodiment of the invention;

FIG. 15A is a perspective view of a surgical accessory support belt in adeflated state according to another embodiment of the invention;

FIG. 15B is a perspective view of the surgical accessory support belt ofFIG. 15A in an inflated state;

FIG. 16 is an elevational view of a tool tip for a single working memberend effector according to another embodiment of the invention;

FIG. 17 is a perspective view of a pair of tool tips for a doubleworking member end effector according to another embodiment of theinvention;

FIG. 18A is a perspective view of a dual tip tool glove for a doubleworking member end effector according to another embodiment of theinvention;

FIG. 18B is a partial cross-sectional view of the dual tip tool gloveassembled with the double working member end effector of FIG. 18A;

FIG. 19 is an exploded perspective view of insulative or resilientsheaths for forceps;

FIG. 20 is a schematic view illustrating manipulation of an in vivo flowtube by a grasping tool;

FIG. 21 is a schematic view illustrating introduction of an in vivo flowtube into the surgical site using a needle; and

FIG. 22 is a schematic view illustrating an in vivo retraction member.

DESCRIPTION OF THE SPECIFIC PREFERRED EMBODIMENTS

As used herein, “end effector” refers to the actual working part that ismanipulatable for effecting a predetermined treatment of a targettissue. For instance, some end effectors have a single working membersuch as a scalpel, a blade, or an electrode. Other end effectors have apair of working members such as forceps, graspers, scissors, or clipappliers, for example.

As used herein, the terms “surgical instrument”, “instrument”, “surgicaltool”, or “tool” refer to a member having a working end which carriesone or more end effectors to be introduced into a surgical site in acavity of a patient, and is actuatable from outside the cavity tomanipulate the end effector(s) for effecting a desired treatment of atarget tissue in the surgical site. The instrument or tool typicallyincludes a shaft carrying the end effector(s) at a distal end, and ispreferably servo mechanically actuated by a telesurgical system forperforming functions such as holding or driving a needle, grasping ablood vessel, and dissecting tissue.

As used herein, the terms “surgical accessory” and “accessory” refer toan assisting member that is introduced into the surgical site in thecavity of the patient to be used by an instrument or tool to perform adesired function in the surgical site.

One type of accessory is loaded in a surgical instrument and applied bythe surgical instrument to a target tissue. For instance, fasteningaccessories are adapted to be used with a fastening tool for fasteningtissues and the like. An example is a clip for use with a clip applierwhich affixes or anchors the clip to a target tissue. Another example isa suture needle with suture material for use with a suturing tool.

Another type of accessory is a single working member accessory such as ablade, a scalpel, a dissection finger, or an electrode, which does notrequire the more complex mechanisms for manipulating multiple workingmembers such as forceps. For instance, a single working member accessorycan be grasped by a tool having a pair of working members in a jaw-likearrangement, which is adapted for manipulating different single workingmember accessories and providing them with the desired degrees offreedom in movement to perform different treatments.

The accessory may be a tool tip that is configured to be releasablycoupled to an end effector working member of the surgical tool to form atool tip for the end effector. For an end effector having a pair ofworking members, the accessory may include a pair of fingers movablysupported on a collar which is configured to be releasably coupled withthe end effector in a coupled position. The pair of fingers mate withthe pair of working members to be movable by the pair of working membersin the coupled position.

The working members of a tool can be modified by sheath accessories. Forinstance, forceps on the working end of a tool can be fitted withinsulating sheaths when desired to inhibit electric current leakage andprevent burning.

Another example of an accessory is a flow tube introduced into thecavity of the patient for providing suction, introducing a gas or aliquid, or transporting other matters into or out of the cavity. Such aflow tube can be grasped by a grasping tool inside the cavity and movedto the desired location for treating a particular area of the patient'sbody.

A retraction accessory includes a gripping portion such as a hook whichcan be manipulated by a grasping tool and used, e.g., to grip a tissueinside the surgical site. The retraction accessory is resiliently biasedby a spring, preferably an adjustable spring, to move to a desiredlocation, thereby retracting the tissue to expose an area in thesurgical site for treatment. The retraction accessory preferably can bemanipulated from inside or outside the body to further position tissueas desired, e.g., by providing a friction slide on the spring mechanismto adjust the spring preload. Further, a selection of springs ofdifferent tensions and spring constants may be provided to the surgeondepending upon the distances involved between the body wall and thetissue to be retracted.

I. Exemplary Telesurgical System

FIG. 1A shows an operator station or surgeon's console 200 of aminimally invasive telesurgical system. The station 200 includes aviewer 202 where an image of a surgical site is displayed in use. Asupport 204 is provided on which an operator, typically a surgeon, canrest his or her forearms while gripping two master controls (not shownin FIG. 1A), one in each hand. The master controls are positioned in aspace 206 inwardly beyond the support 204. When using the controlstation 200, the surgeon typically sits in a chair in front of thecontrol station 200, positions his or her eyes in front of the viewer202 and grips the master controls one in each hand while resting his orher forearms on the support 204.

FIG. 1B shows a cart or surgical station 300 of the telesurgical system.In use, the cart 300 is positioned close to a patient requiring surgeryand is then normally caused to remain stationary until a surgicalprocedure to be performed has been completed. The cart 300 typically haswheels or castors to render it mobile. The station 200 is typicallypositioned remote from the cart 300 and can be separated from the cart300 by a great distance, even miles away, but will typically be usedwithin an operating room with the cart 300.

The cart 300 typically carries three robotic arm assemblies. One of therobotic arm assemblies, indicated by reference numeral 302, is arrangedto hold an image capturing device 304, e.g., an endoscope, or the like.Each of the two other arm assemblies 10 respectively, includes asurgical instrument 14. The endoscope 304 has a viewing end 306 at aremote end of an elongate shaft thereof. It will be appreciated that theendoscope 304 has an elongate shaft to permit its-viewing end 306 to beinserted through an entry port into an internal surgical site of apatient's body. The endoscope 304 is operatively connected to the viewer202 to display an image captured at its viewing end 306 on the viewer202. Each robotic arm assembly 10 is normally operatively connected toone of the master controls. Thus, the movement of the robotic armassemblies 10 is controlled by manipulation of the master controls. Theinstruments 14 of the robotic arm assemblies 10 have end effectors thatare mounted on wrist members which are pivotally mounted on distal endsof elongate shafts of the instruments 14, as is described in greaterdetail below. It will be appreciated that the instruments 14 haveelongate shafts to permit the end effectors to be inserted through entryports into the internal surgical site of a patient's body. Movement ofthe end effectors relative to the ends of the shafts of the instruments14 is also controlled by the master controls.

The robotic arms 10, 10, 302 are mounted on a carriage 97 by means ofsetup joint arms 95. The carriage 97 can be adjusted selectively to varyits height relative to a base 99 of the cart 300, as indicated by arrowsK. The setup joint arms 95 are arranged to enable the lateral positionsand orientations of the arms 10, 10, 302 to be varied relative to avertically extending column 93 of the cart 300. Accordingly, thepositions, orientations and heights of the arms 10, 10, 302 can beadjusted to facilitate passing the elongate shafts of the instruments 14and the endoscope 304 through the entry ports to desired positionsrelative to the surgical site. When the surgical instruments 14 andendoscope 304 are so positioned, the setup joint arms 95 and carriage 97are typically locked in position.

As shown in FIGS. 2A and 2B, each robotic arm assembly 10 includes anarticulated robotic arm 12 and a surgical instrument 14 mounted thereon.As best seen in FIG. 3, the surgical instrument 14 includes an elongateshaft 14.1 and a wrist-like mechanism 50 located at a working end of theshaft 14.1. A housing 53, arranged releasably to couple the instrument14 to the robotic arm 12, is located at an opposed end of the shaft14.1. The shaft 14.1 is rotatably coupled to the housing 53 at 55 toenable angular displacement of the shaft 14.1 relative to the housing 53as indicated by arrows H. In FIG. 2A, and when the instrument 14 iscoupled or mounted on the robotic arm 12, the shaft 14.1 extends alongan axis 14.2. The instrument 14 typically is releasably mounted on acarriage 11, which can be driven to translate along a linear guideformation 24 of the arm 12 in the direction of arrows P.

Tie robotic arm 12 is typically mounted on a base or platform at an endof its associated setup joint arm 95 by a bracket or mounting plate 16.The robotic arm 12 includes a cradle 18, an upper arm portion 20, aforearm portion 22, and the guide formation 24. The cradle 18 ispivotally mounted on the plate 16 in a gimbaled fashion to permitrocking movement of the cradle 18 in the direction of arrows 26 about apivot axis 28 (FIG. 2B). The upper arm portion 20 includes link members30, 32 and the forearm portion 22 includes link members 34, 36. The linkmembers 30, 32 are pivotally mounted on the cradle 18 and are pivotallyconnected to the link members 34, 36. The link members 34, 36 arepivotally connected to the guide formation 24. The pivotal connectionsbetween the link members 30, 32, 34, 36, the cradle 18, and the guideformation 24 are arranged to constrain the robotic arm 12 to move in aspecific manner.

The movements of the robotic arm 12 are illustrated schematically inFIG. 4. The solid lines schematically indicate one position of therobotic arm and the dashed lines indicate another possible position intowhich the arm can be displaced from the position indicated in solidlines.

It will be understood that the axis 14.2 along which the shaft 14.1 ofthe instrument 14 extends when mounted on the robotic arm 12 pivotsabout a pivot center or fulcrum 49. Thus, irrespective of the movementof the robotic arm 12, the pivot center 49 normally remains in the sameposition relative to the stationary cart 300 on which the arm 12 ismounted. In use, the pivot center 49 is positioned at a port of entryinto a patient's body when an internal surgical procedure is to beperformed. It will be appreciated that the shaft 14.1 extends throughsuch a port of entry, the wrist-like mechanism 50 then being positionedinside the patient's body. Thus, the general position of the mechanism50 relative to the surgical site in a patient's body can be changed bymovement of the arm 12. Since the pivot center 49 is coincident with theport of entry, such movement of the arm does not excessively effect thesurrounding tissue at the port of entry.

As can best be seen in FIG. 4, the robotic arm 12 provides three degreesof freedom of movement to the surgical instrument 14 when mountedthereon. These degrees of freedom of movement are firstly the gimbaledmotion indicated by arrows 26, pivoting or pitching movement asindicated by arrows 27 and the linear displacement in the direction ofarrows P. Movement of the arm as indicated by arrows 26, 27 and P iscontrolled by appropriately positioned actuators, e.g., electricalmotors or the like, which respond to inputs from its associated mastercontrol to drive the arm 12 to a desired position as dictated bymovement of the master control. Appropriately positioned sensors, e.g.,potentiometers, encoders, or the like, are provided on the arm and itsassociated setup joint arm 95 to enable a control system of theminimally invasive telesurgical system to determine joint positions, asdescribed in greater detail below. The term “sensors” as used herein isto be interpreted widely to include any appropriate sensors such aspositional sensors, velocity sensors, or the like. By causing therobotic arm 12 selectively to displace from one position to another, thegeneral position of the wrist-like mechanism 50 at the surgical site canbe varied during the performance of a surgical procedure.

Referring now to the wrist-like mechanism 50 of FIG. 5, the working endof the shaft 14.1 is indicated at 14.3. The wrist-like mechanism 50includes a wrist member 52. One end portion of the wrist member 52 ispivotally mounted in a clevis 17 on the end 14.3 of the shaft 14.1 bymeans of a pivotal connection 54. The wrist member 52 can pivot in thedirection of arrows 56 about the pivotal connection 54. An end effector58 is pivotally mounted on an opposed end of the wrist member 52. Theend effector 58 has two parts 58.1, 58.2 together defining a jaw-likearrangement.

The end effector can be in the form of any desired surgical tool, e.g.,having two members or fingers which pivot relative to each other, suchas a clip applier for anchoring clips, scissors, two-fingered bluntdissection tools, forceps, pliers for use as needle drivers, or thelike. Moreover, it can include a single working member, e.g., a scalpel,cautery electrode, or the like. When a different tool is desired duringthe surgical procedure, the tool 14 is simply removed from itsassociated arm and replaced with an instrument bearing the desired endeffector.

In FIG. 5, the end effector 58 is a grip applier. The end effector 58 ispivotally mounted in a clevis 19 on an opposed end of the wrist member52, by means of a pivotal connection 60. The free ends 11, 13 of theparts 58.1, 58.2 are angularly displaceable about the pivotal connection60 toward and away from each other as indicated by arrows 62, 63. Themembers 58.1, 58.2 can be displaced angularly about the pivotalconnection 60 to change the orientation of the end effector 58 as awhole, relative to the wrist member 52. Thus, each part 58.1, 58.2 isangularly displaceable about the pivotal connection 60 independently ofthe other, so that the end effector 58, as a whole, is angularlydisplaceable about the pivotal connection 60 as indicated in dashedlines in FIG. 5. Furthermore, the shaft 14.1 is rotatably mounted on thehousing 53 for rotation as indicated by the arrows 59. Thus, the endeffector 58 has three degrees of freedom of movement relative to the arm12 in addition to actuation of the end effector members to, e.g., griptissue, namely, rotation about the axis 14.2 as indicated by arrows 59,angular displacement as a whole about the pivot 60 and angulardisplacement about the pivot 54 as indicated by arrows 56. By moving theend effector within its three degrees of freedom of movement, itsorientation relative to the end 14.3 of the shaft 14.1 can selectivelybe varied. The movement of the end effector relative to the end 14.3 ofthe shaft 14.1 is controlled by appropriately positioned actuators,e.g., electrical motors, or the like, which respond to inputs from theassociated master control to drive the end effector 58 to a desiredorientation as dictated by movement of the master control. Furthermore,appropriately positioned sensors, e.g., encoders, or potentiometers, orthe like, are provided to permit the control system of the minimallyinvasive telesurgical system to determine joint positions.

One of the master controls 700 is shown in FIG. 6C. As seen in FIG. 6A,a hand held part or wrist gimbal 699 of the master control device 700has an articulated arm portion including a plurality of members or links702 connected together by pivotal connections or joints 704. The surgeongrips the part 699 by positioning his or her thumb and index finger overa pincher formation 706. The surgeon's thumb and index finger aretypically held on the pincher formation 706 by straps (not shown)threaded through slots 710. When the pincher formation 706 is squeezedbetween the thumb and index finger, the fingers or end effector elementsof the end effector 58 close. When the thumb and index finger are movedapart the fingers of the end effector 58 move apart in sympathy with themoving apart of the pincher formation 706. The joints of the part 699are operatively connected to actuators, e.g., electric motors, or thelike, to provide for, e.g., force feedback, gravity compensation, and/orthe like. Furthermore, appropriately positioned sensors, e.g., encoders,or potentiometers, or the like, are positioned on each joint 704 of thepart 699, so as to enable joint positions of the part 699 to bedetermined by the control system.

The part 699 is typically mounted on an articulated arm 712 as indicatedin FIG. 6B. Reference numeral 4 in FIGS. 6A and 6B indicates thepositions at which the part 699 and the articulated arm 712 areconnected together. When connected together, the part 699 can displaceangularly about an axis at 4.

The articulated arm 712 includes a plurality of links 714 connectedtogether at pivotal connections or joints 716. The articulated arm 712further has appropriately positioned actuators, e.g., electric motors,or the like, to provide for, e.g., force feedback, gravity compensation,and/or the like. Furthermore, appropriately positioned sensors, e.g.,encoders, or potentiometers, or the like, are positioned on the joints716 so as to enable joint positions of the articulated arm 712 to bedetermined by the control system.

To move the orientation of the end effector 58 and/or its position alonga translational path, the surgeon simply moves the pincher formation 706to cause the end effector 58 to move to where he wants the end effector58 to be in the image viewed in the viewer 202. Thus, the end effectorposition and/or orientation is caused to follow that of the pincherformation 706.

The master control devices 700, 700 are typically mounted on the station200 through pivotal connections at 717 as indicated in FIG. 6B. Asmentioned above, to manipulate each master control device 700, thesurgeon positions his or her thumb and index finger over the pincherformation 706. The pincher formation 706 is positioned at a free end ofthe part 699 which in turn is mounted on a free end of the articulatedarm portion 712.

The electric motors and sensors associated with the robotic arms 12 andthe surgical instruments 14 mounted thereon, and the electric motors andsensors associated with the master control devices 700 are operativelylinked in the control system. The control system typically includes atleast one processor, typically a plurality of processors, for effectingcontrol between master control device input and responsive robotic armand surgical instrument output and for effecting control between roboticarm and surgical instrument input and responsive master control outputin the case of, e.g., force feedback. An example of a suitable controlsystem is described in U.S. application Ser. No. 09/373,678, entitled“Camera Referenced Control in a Minimally Invasive Surgical Apparatus”,filed on Aug. 13, 1999.

II. In Vivo Accessories

To minimize the need to remove tools from the surgical site for toolreplacement or instrument loading, the present invention provides waysto present a variety of accessories in vivo. The surgeon can manipulatethese in vivo accessories using tools already in the surgical site andadapt them for performing different functions without the need to removethe tools from the surgical site. A number of examples of in vivoaccessories are provided herein below.

A. Instrument Loading Accessories

Certain instruments are used by loading accessories specifically adaptedfor use with the particular instruments to perform the intended tasks.For example, fastening accessories such as clips are specificallyadapted for use with a clip applier. The clips are loaded in a clipapplier which affixes or anchors the clips one at a time to a targettissue.

FIGS. 7 and 8 show in greater detail the clip applier end effector 58for the tool 14 of FIG. 5. The parts 58.1, 58.2 of the end effector 58are typically the same so as to keep production costs low. Accordingly,the parts 58.1, 58.2 each include an elongate finger portion or endeffector element 58.3. The finger portion 58.3 is integrally formed withan end effector mounting formation in the form of, e.g., a pulleyportion 58.5. The pulley portion 58.5 defines a circumferentiallyextending channel 58.6 in which an elongate element in the form of,e.g., an activation cable, is carried, as described in greater detailherein below.

The pulley portion 58.5 includes an axially extending, centrallydisposed hole 58.7 through which a pivot pin of the pivotal connection60 extends. A generally circumferentially directed hole 58.8 extendsthrough a nape region of the finger portion 58.3 and generally inregister with the circumferentially extending channel 58.6. The hole58.8 has a first portion 58.9 and a second portion 58.10 having adiameter greater than the first portion 58.9. In use, the activationcable has a thickened portion along its length which seats in the holeportion 58.10, the rest of the activation cable then extending along thechannel 58.6 in opposed directions. The thickened portion is crimped inits seated position in the hole portion 58.10 so as to anchor the cablein the hole 58.8. It will be appreciated that a greater force isnecessary to clamp the free ends together when gripping an objecttherebetween, than that which is required to open the free ends 11, 13.Thus, the thickened portion of the cable is urged against an annularstepped surface between the hole portion 58.9 and the hole portion58.10, when the free ends 11, 13 are urged into a closed condition. Thepart 58.1, 58.2 has an operatively inwardly directed face 58.11 whichrides against the face 58.11 of the other one of the parts 58.1, 58.2.

In use, a clip 75, as indicated in FIG. 8, is positioned between thefinger portions 58.3. Opposed limbs 75.1, 75.2 of the clip 75 arepositioned in longitudinally extending recesses or seats 58.13 in eachof the finger portions 58.1, 58.2. It is important that the clip issecurely seated in the clip applier 58 until the clip applier is causedto anchor the clip in position. If the clip 75 is not securely seated,the clip 75 could become dislocated from the clip applier 58. In such acase, valuable time could be lost in trying to find and recover the clip75 from the surgical site. To cause the clip 75 to seat securely on theclipper pliers 58, the portions 58.1 58.2 are biased or urged in aclosing direction so as to clamp the clip 75 in the opposed seats orrecesses 58.13. The biasing or urging arrangement to cause such clampingof the clip 75 in the seats 58.13, as well as the mechanisms foroperating the clip applier end effector 58, are discussed in detail inU.S. application Ser. No. 09/398,958, entitled “Surgical Tools for Usein Minimally Invasive Telesurgical Applications”, (Docket No.17516-4410), filed on Sep. 17, 1999, the entirety of which is hereinincorporated by reference. Alternatively, as described in the '958application, instead of being urged or biased towards each other,portions 58.1 and 58.2 can be constructed in such a way (with open-endedrecesses 58.13) as to open (e.g., against mechanical stops) to apredetermined angular position slightly less than the angle of the clipsto be used. Thus, the natural resistance of the clip to deformationprovides sufficient friction when loaded into the clip applier that aseparate biasing means is unnecessary.

Normally, in use, the clip applier having the end effector 58 is removedfrom the surgical site, a clip 75 is then positioned between the fingerportions 58.3, and then the end effector 58 is reintroduced into thepatient's body so as to apply or anchor the clip 75 where required. Toapply the clip, the master controls are manipulated to cause the clipapplier to close so as to bend the clip 75. When the clip 75 has beenapplied, the end effector 58 can again be opened and removed from thesurgical site, another clip 75 can then be positioned between the fingerportions 58.3, and the end effector can again be introduced to thesurgical site to apply that clip and so on, until all the required clipshave been applied or anchored in position. This process istime-consuming.

In accordance with an embodiment of the present invention, the clips 75are introduced into the surgical site 77 in a cavity of a patient by adedicated surgical accessory support in the form of a cartridge 76. Theend effector 58 of the clip applier can be manipulated servomechanically or manually from outside the cavity to load a clip 75 fromthe cartridge 76 and affix the clip 75 to a target tissue inside thecavity. The end effector 58 need not be removed from the surgical site77 for loading the clip 75 and reintroduced into the surgical site 77.

In another embodiment shown in FIG. 10, the clips 75 are supported onthe shaft of another tool 81 having an end effector 81.1 in a“piggyback” arrangement, thereby eliminating the need to open a separateport for introducing a dedicated accessory support into the surgicalsite 77. Cannula sleeves 77.1 are typically provided through the wall77.2 of the patient's body for introducing the surgical tools andaccessory support into the surgical site 77.

As can be understood with reference to FIG. 10, releasably mounting asurgical accessory (such as clip 75) to a robotically controlledstructure (such as tool 81) may facilitate mating of the accessory withtool 14. Tool 81 can be easily and accurately positioned in a field ofview of scope 306 for loading the clip applier 58. Tool 14 and/or tool81 may be positioned and moved to accurately transfer clip 75 from tool81 to clip applier 58 within the field of view from the scope using therobotic servomechanism to generate the desired clip loading forces,without having to verbally coordinate hand movements of two differentpersons.

B. Single Working Member Accessories

Another type of accessory is a single working member accessory such as ablade, a scalpel, a dissection finger, or an electrode, which does notrequire the more complex mechanisms for manipulating multiple workingmembers such as forceps and clip appliers. For instance, the singleworking member accessory can be grasped by jaw-like working members suchas forceps on a tool which can be used for manipulating different singleworking member accessories and providing them with the desired degreesof freedom of movement to perform different treatments on tissues in thesurgical site.

FIG. 11 shows examples of single working member accessories, including acautery or electrosurgical hook 118, a cautery blade 119, a scalpel 120,and a dissection finger 121 or Kittner for blunt dissection. Anotherexample of a single working member accessory is an electrocauteryelectrode 122 used to generate an electrical current at a surgical siteso as to burn or seal, e.g., ruptured blood vessels. In use, the patientis earthed and a voltage is supplied to the electrode 122. Anelectrically conductive cable 124 is connected to the electrode 122. Inuse, the cable 124 couples the electrode 122 to an appropriateelectrical source outside the surgical site, preferably through anaccessory body wall port. The conductive cable 124 is typically sheathedin an insulative material such as, e.g., TEFLON™ The electrode, in theform of a blade or hook, e.g., or other accessories may be dangled intothe patient's body cavity through a body wall port by way of the cableand/or an associated spring mechanism, as disclosed in the context ofFIGS. 16 and 18A. Grasping tool can be used to grasp one of the singleworking member accessories and manipulate its movement to treat thetarget tissue. Exemplary electrosurgical implements are disclosed inU.S. application Ser. No. 09/415,568 (Attorney Docket No. 17516-007200),entitled “Minimally Invasive Surgical Hook Apparatus & Method for UsingSame,” filed on Oct. 8, 1999, the entirety of which is hereinincorporated by reference.

It will be appreciated that should the distance between the electrode122 and the patient be relatively great when a voltage is applied,current may jump from the electrode 122 to other conductive parts of theinstrument. In such a case, current can be passed from the grasping toolto the patient along a path of least resistance, e.g., at the entry portcoincident with the center of rotation 49 (see FIGS. 2A and 2B). Thismay cause unnecessary burning at the entry port. One way of avoidingsuch current flow is to insulate the electrode 122 from the graspingtool so as to inhibit current leakage from the electrode 122 to thetool. Accordingly, the components of the grasping tool may be made ofnon-conductive material such as, e.g., ULTEM™ or VECTRAN™ The shaft ofthe tool is typically made entirely from a nonconductive material, or atleast sheathed in such a material, to insulate the shaft from thepatient, in particular in the region of the port of entry. The preferrednonconductive material for the shaft 114.1 comprises an electrical gradefiberglass/vinyl ester composite material. A shaft of stainless steel orcarbon fiber may be coated with, e.g., a nylon or parylene, such asNylon-11 or Parylene C.

FIG. 11A shows one way of performing electrocautery with superior safetyand precision. The electrode 122 is grasped by a grasping tool such asforceps 125 having insulative components for making contact with theelectrode 122. Alternatively, the electrode 22 can be partially sheathedin nonconductive material for making contact with the other tool.Another tool 127A is used to hold a tissue such as a vessel 129A. Theportion of the tool 127A in contact with the tissue 129A is electricallyconductive. The electrode 122 is coupled with one lead of a bipolarsystem, while the grasping tool 127A holding the tissue 129A is coupledwith the other lead of the bipolar system. The electrode 122 is anactive electrode and the tool 127A is a passive electrode. The tissuedisposed between the active and passive electrodes complete theelectrical circuit of the bipolar system. When sufficient power isintroduced, coagulation of the tissue between the electrode 122 and thetool 127A occurs.

In another embodiment shown in FIG. 11B, the tool 127B is placed behindthe target area of the tissue 129B, while the electrode 122 approachesthe target area from the front to define a specific coagulation zone. Inboth FIGS. 11A and 11B, the coagulation zone for the tissue 129B iswell-defined to provide safe, direct electrocauterization.

FIG. 12 shows an example of a grasping tool having forceps 110 forgrasping and manipulating one of the single working member accessoriesinside the surgical site. The forceps 110 is mounted on a wristmechanism similar to the wrist mechanism 50. The forceps 110 has twoworking members 110.1, 110.2. The working members 110.1, 110.2 areslightly bent to define a space 112 between them. In use, it isdifficult to provide force feedback to the master controls. Thus, itcould happen that an organ, or tissue, or the like, can be grasped byforceps with too much force which may unnecessarily damage such organ ortissue. To inhibit this, the space 112 is provided. The members 110.1,110.2 have a degree of resilience. Thus, when the forceps is used, thesurgeon manipulating the master controls can obtain an indication of theforce applied when grasping with the forceps 110 by visually monitoringresilient deflection of the members 110.1, 110.2 relative to each other,all as described in application Ser. No. 09/398,958.

The single working member accessories can be introduced into thesurgical site in any suitable way. For instance, each accessory can beconnected to a cable and inserted through an opening into the surgicalsite and be removed from the site by pulling on the cable from outsidethe patient's body. Alternatively, an accessory support can be used tointroduce a plurality of accessories into the surgical site.

FIG. 13 illustrates a surgical accessory support in the form of a block126 for holding the accessories such as the cautery blade 119, scalpel120, and dissection finger 121. The block 126 is introduced through thecavity wall 77.2 via a cannula sleeve 77.1. The support block 126 in oneembodiment is made of a foam material or the like which deflects toreleasably secure the accessories therein. The accessories can beremoved by the grasping tool 110 inside the surgical site to perform adesired treatment and then returned to the block 126 after use. Theblock 126 is particularly suitable for supporting sharp objects such asblades and scalpels.

FIG. 14 shows a container or box 130 as another embodiment of a surgicalaccessory support. The box 130 extends through the cavity wall 77.2 viaa cannula sleeve 77.1. A handle 132 supports the box 130 in the surgicalsite from outside the patient's cavity. The box 130 includes acompartment 134 for housing accessories and a door 136 which can beopened to allow access to the accessories, and be closed duringtransportation of the box 136 into and out of the surgical site. Avariety of mechanisms can be used to control movement of the door 136.In the embodiment shown, a control rod 138 is connected with the door136 and extends through the end of the handle 132. The control rod 138allows the operator to open the door 136 by pushing the rod 138 towardthe handle 132 and to close the door 130 by pulling the rod 138 awayfrom the handle 132. A physical or solenoid-activated latch might beincluded to lock the door in an open configuration during an operation,if desired. It is appreciated that other devices can be used forintroducing the surgical accessories into the surgical site andsupporting them therein.

In another embodiment as shown in FIG. 15A, an inflatable tool belt orsupport 730 can be used to hold accessories 732 such as needles, gauze,or blades, and can be inserted into the surgical site through a portwith the tool belt 730 in a deflated state. The accessories 732 may bereleasably attached to the tool belt 730 in any suitable manner, such asthe use of velcro or the like. After the tool belt 730 has been insertedinto the surgical site, it can be inflated in a manner similar to aballoon catheter to expose the accessories 732 so that they may be usedin the surgical site, as illustrated in FIG. 15B. The inflated tool belt730 provides support for the accessories 732 and may cause theaccessories to stand in an erect position, making them more easilygraspable by a grasping tool such as forceps 110 or the like. The toolbelt 730 can be deflated for retraction. A mechanism similar to thoseused for balloon catheters can be used for inflating and deflating thetool belt 730.

Single working member end effectors, such as a blade or a scalpel on asurgical tool can also be replaced inside the patient without removingthe tool from the patient's body cavity. Mechanisms allowing suchreplacement include, e.g., a blade mounted on a pliable polymeric sleevethat fits snugly over a finger-like projection. For replacement, thetool is simply loosened and attached to an accessory belt of the typedisclosed herein, and replaced with another single member tool having asimilar sheath mounting structure. Alternative methods of mountingsingle member tools to the end of a robotic tool are disclosed in FIGS.17-19 of U.S. application Ser. No. 09/398,598, which is incorporatedherein by reference in its entirety.

C. Tool Tip Accessories

FIG. 16 shows an example of a removable tool tip 740 for a singleworking member end effector 742 having a drive pulley 744 connected witha tool end 746. The tool tip 740 is one of a plurality of tool tipaccessories that can be introduced separately into the surgical tool sothat the end effector 742 can be fitted with different tool tips forperforming different procedures as desired without having to leave thesurgical site. Examples of tool tips include blades, scalpels,electrodes, and the like. The tool tip 740 and the tool end 746 areconfigured to form a mating connection. The tool tip 740 can be graspedby a grasping tool and be snapped or wedged onto the tool end 746. Inthe embodiment shown, the tool tip 740 has a protrusion 747 thatdetachably fits into a slot or recess 748 of the tool end 746. To removethe tool tip 740, the grasping tool can be used to grasp the tool tip740 and disengage it from the tool end 746. It is understood that otherdetachable mechanisms may be used for connecting the tool tip 740 withthe tool end 746 including, for example, cantilever-type snaps or thelike.

In FIG. 17, a double working member end effector 750 has a pair of toolends 752 that can be fitted with two tool tips 754 by mating protrusions757 of the tool tips 754 with slots 758 of the tool ends 752. A pair ofdrive pulleys 756 are connected with the tool ends 752 to move the tooltips 754 in a jaw-like arrangement. The tool tips 754 may include setsof forcep tips or other jaw-like working member tips of varying sizes orshapes.

Another way to provide different tool tips for a double working memberend effector is to use a dual tip tool glove 760 as illustrated in FIGS.18A and 18B. As shown in FIG. 18A, the tool glove 760 includes a pair offingers 762 that are pivotally attached to a tool glove support orcollar 764. The collar 764 is a hollow member configured to be placedover the wrist member 766 of a double working member end effector 768.The wrist member 766 supports a pair of drive pulleys 770 that areconnected to a pair of tool ends or nubs 772. The tool nubs 772 areinserted into a pair of openings 774 of the pair of fingers 762 of thetool glove 760 when the tool glove 760 is joined with the wrist member766 in the attached position shown in FIG. 18B. The pulleys 770 areactuatable (typically by cables) to rotate the tool nubs 772 which inturn cause the fingers 762 to rotate and to move, e.g., in a jaw-likemanner.

The collar 764 is configured to be releasably locked onto the wristmember 766. As best seen in FIG. 18B, the collar 764 includes a springretention ring 776 which applies a resilient force to wrap around agroove 778 on the wrist member 766 to resiliently lock the collar 764onto the wrist member 766 in the attached position. The spring retentionring 776 is typically a metal ring held in a groove in the collar 764,and can split to expand in diameter and allow the collar 764 to beplaced over the wrist member 766. A grasping tool may be used tomanipulate the tool glove 760 for assembly with the wrist member 766.When the retention ring 776 reaches the groove 778 on the wrist member766, it contracts around the groove 778 from the split position, therebyreleasably locking the collar 764 onto the wrist member 766. Todisconnect the tool glove 760 from the wrist member 766, a sufficientpulling force is applied to the tool glove 760 via the grasping tool toovercome the resilient force of the retention ring 776. It isappreciated that other releasable locking mechanisms may be used forlocking the tool glove 760 onto the wrist member 766 of the end effector768. Further, the fingers 762 of the tool glove 760 may have otherconfigurations.

It has been found that when a surgeon uses a grasper to grab and hold anaccessory tool for an extended period of time to perform surgery, in themanner previously described, the surgeon at some point may wish to relaxhis grip on the master control without the grasper losing its grip onthe accessory tool. Further, the surgeon may wish to operate using theaccessory tool without having to constantly grip the master control toactuate the grasper to grip the accessory. This ability to avoidconstantly having to actuate two-member tools to close/grip is alsodesirable, e.g., during suturing, when the surgeon may need to exert alarge gripping force on a needle while manipulating the needle to sewtissue. Such maneuvers sometimes can prove awkward and tiring to thesurgeon's hands if too much gripping in involved over a long period oftime. This problem is addressed by providing the surgeon with theability to “lock” the graspers closed, after actuation, so that thegraspers remain closed and gripping, e.g., a needle or accessory tooluntil the surgeon commands the graspers to do otherwise. Locking thetwo-membered tool in a closed/gripping position allows the surgeon torelax his gripping pressure on the master control after actuation of thetool. This functionality can be implemented in any number of ways, suchas by the surgeon physically- or voice-activating a switch or button orlatch on the master control while the tool is actuated, to instruct thesystem to maintain the tool's actuation until a further command isreceived, or by programming the control computer to detect when theoperator intends to actuate the virtual locking function, e.g., bydetecting a threshold closing force on the masters applied over aspecific period of time, such as two seconds. Several threshold forces,corresponding to several different closing/locking forces might beprovided as desired. Once the command is given, the computer would lockthat particular tool into position and either maintain the particularforce applied by the surgeon at the time the locking command wasprovided, or would maintain a maximum gripping force (depending upon howthe system is configured) without further gripping force from thesurgeon on the corresponding master control, until a further “unlock”command is given. Upon activation in this manner, the surgical systempreferably would provide the surgeon with a perceivable indication thatthe tool was locked, e.g., through an audible sound, illumination of alocking light, illumination of an icon on the surgeon s console screen,etc. One example of a latch locking mechanism is shown in FIG. 6D.Sliding button 703 in slot 701 has two positions, as more clearly seenin FIG. 6E. When in a first position, latches 705 and 707 do not catchwhen the pincher formation 706 is closed. When in a second position,however, latches 705 and 707, preferably made of a resilient metal suchas spring steel (similar to the latching mechanism on the Castro-ViejoNeedle Drivers made by Scanlan), do catch, thereby keeping the masterlocked into position and the slave end effector actuated until released.In this embodiment, the pincher formation remains in a closed profile.If desired, the end effector could be locked as described above whileleaving the surgeon free to continue to manipulate the pincher formationas before—e.g., for comfort reasons—but without giving the surgeon theability to further affect the actuation of the end effector until“unlocking” the mechanism.

The tool is preferably unlocked in similar manner by a threshold outwardforce on the master actuation controls, or activation of a separatebutton or voice control. Upon unlocking, the surgeon would again be ableto control the end effector as before, and preferably would be providedwith an indication from the system that the unlock command had beenreceived, such as another audible or visual signal or elimination of thepreviously illuminated icon.

D. Sheath Accessories

Sheath accessories can be used to modify the working members of asurgical tool. For instance, a pair of jaw-like working members such asforceps on the working end of a tool can be fitted with insulatingsheaths or resilient sheaths when desired.

FIG. 19 shows forcep sheaths 140 configured to fit over working members110.1, 110.2 of forceps 110, forming a mated connection therewith. Forinsulation, the forcep sheaths 140 are made of an insulative materialsuch as rubber, VECTRAN™, ULTEM™, or the like. In an alternativeembodiment, the forcep sheaths 140 are made of a resilient material suchas an elastomer for protecting tissues from damage caused by excessivepressure exerted by the forceps 110. The surgeon can visually monitorthe deformation of the resilient sheaths 140 and adjust the grippingforce accordingly. The sheaths 140 can be introduced into the surgicalsite by the container of FIG. 14, and be placed over the forceps 110while inside the body cavity using another grasping tool, for example.

E. Other Accessories

Another example of an accessory is a flow tube 150 introduced into thecavity of the patient for providing suction, introducing a gas or aliquid, or transporting other matters into or out of the cavity, asshown in FIG. 20. The flow tube 150 can be grasped, for example, by agrasping tool having forceps 110 inside the cavity and moved to thedesired location for treating a particular area of the patient's body.

In FIG. 20, the flow tube 150 is inserted through the cavity wall 77.2of a patient into the cavity via a tube support 152. The flow tube 150is typically flexible. The flow tube 150 includes an opening 154 at adistal end. The flow tube 150 can be connected with a vacuum source toprovide suction to draw out fluid or other matters from the cavitythrough the opening 154, or an external source for introducing a fluidin the form of a liquid such as saline or a gas such as CO.sub.2 intothe surgical site, or the like. In one embodiment, the flow through theopening 154 of the tube 150 can be modulated by adjusting the grip ofthe grasper on the tube 150.

To minimize interference with the manipulation of tools in the surgicalsite, the flow tube 150 is advantageously resiliently biased by a spring156 to return to the location near the tube support 152 at the apertureof the cavity wall 77.2. The spring 156 compresses when the tube 150 ispulled further into the surgical site and causes the tube 150 toautomatically return closer to the wall aperture when the tube 150 isreleased by the forceps 110. In this way, the flow tube 150 stays clearof the remaining area of the surgical site. It is appreciated that othersuitable resilient mechanisms may be employed, and that a similarresilient mechanism can be adapted for use with other accessoryintroducing devices.

In some cases, the tube 150 is sufficiently small that the tube support152 is no larger in cross-section than a typical hypodermic needle. FIG.21 shows the use of a hollow needle 158 for introducing the flow tube150 into the internal cavity 77. A pad 159 is affixed to the externalsurface of the cavity wall 77.2 of the patient. The pad 159 is typicallymade of a rubber or foam-like material, and may include a self-adheringsurface for affixing to the external surface. The needle 158 piercesthrough the pad 159 and cavity wall 77.2 carrying the flow tube 150through its core into the cavity 77. In a specific embodiment, theneedle is a small gauge Veress needle.

Another example of an accessory is a retraction member 160 introducedthrough the cavity wall 77.2 of a patient via a support housing 162 forretracting tissue or the like, as illustrated in FIG. 22. The distalportion of the housing 162 which extends through the cavity wall 77.2 isdesirably small to minimize the size of the incision. In a specificembodiment, the distal portion of the housing 162 is as small as a 12gage needle. The retraction member 160 includes a gripping portion suchas a hook 164 or the like for securing a tissue 168 or other objectsinside the cavity. The retraction member 160 is connected with a piston165 which is slidably disposed in the support housing 162. A spring 166biases the piston 165 away from the cavity wall 77.2 and, as a result,biases the retraction member 160 toward the distal portion of thesupport 162 at the opening of the cavity wall 77.2. The retractionmember 160 can be grasped, for example, by a grasping tool inside thecavity to secure the tissue 168 with the hook 164. When the retractionmember 160 is released, the biasing force of the spring 166 returns theretraction member 160 to the position nearer the opening of the cavitywall 77.2, thereby retracting the target tissue 168 from its originallocation indicated at 168A. The displacement of the tissue 168 exposesthe desired target area for treatment.

The above-described arrangements of apparatus and methods are merelyillustrative of applications of the principles of this invention andmany other embodiments and modifications may be made without departingfrom the spirit and scope of the invention as defined in the claims. Forinstance, other telesurgical systems, e.g., without a remote center ofmotion, and surgical tools can be used to perform surgery with the invivo accessories. The examples of surgical accessories and ways ofpresenting them in vivo are illustrative and not exhaustive. Additionalillustrative examples of surgical accessories that can be provided invivo in accordance with the present invention include various gaugeneedles and/or threads or sutures, gauze, and the like. The scope of theinvention should, therefore, be determined not with reference to theabove description, but instead should be determined with reference tothe appended claims along with their full scope of equivalents.

1-4. (canceled)
 5. A method for adapting a surgical instrument in vivofor performing a medical procedure, the method comprising: grasping asurgical accessory which has been inserted into a patient body with agrasping tool which has been inserted into the patient body; andmanipulating the grasping tool to attach the grasped surgical accessoryto a tip of a surgical instrument which has been inserted into thepatient body.
 6. The method of claim 5, further comprising inserting thesurgical accessory into the patient body.
 7. The method of claim 6,wherein inserting the surgical accessory into the patient bodycomprises: inserting an accessory introducer into the patient body,wherein a plurality of surgical accessories, which includes the surgicalaccessory, is coupled to the accessory introducer so that the surgicalaccessory is inserted into the patient body when the accessoryintroducer is inserted into the patient body.
 8. The method of claim 7,wherein inserting an accessory introducer into the patient bodycomprises: inserting a container into the patient body, wherein theplurality of surgical accessories is contained in the container.
 9. Themethod of claim 7, wherein inserting an accessory introducer into thepatient body comprises: inserting a support into the patient body,wherein the plurality of surgical accessories is held by the support.10. The method of claim 5, wherein manipulating the grasping tool toattach the grasped surgical accessory to a tip of a surgical instrumentwhich has been inserted into the patient body comprises: manipulatingthe grasping tool to attach the grasped surgical accessory to the tip ofthe surgical instrument by snap fitting a protrusion of the graspedsurgical accessory into a slot of the tip of the surgical instrument.11. The method of claim 5, wherein manipulating the grasping tool toattach the grasped surgical accessory to a tip of a surgical instrumentwhich has been inserted into the patient body comprises: manipulatingthe grasping tool to attach the grasped surgical accessory to the tip ofthe surgical instrument by placing a collar of the grasped surgicalaccessory over a wrist member of the surgical instrument so that aspring retention ring of the collar applies a resilient force to wraparound a groove of the wrist member.
 12. The method of claim 5, whereinthe grasped surgical accessory is a forceps sheath, and whereinmanipulating the grasping tool to attach the grasped surgical accessoryto a tip of a surgical instrument which has been inserted into thepatient body comprises: manipulating the grasping tool to attach thegrasped surgical accessory to the tip of the surgical instrument byplacing the forcep sheath over a working member on the tip of thesurgical instrument.